Corresponding author at: Universidad Nacional de Colombia, Calle 42 22 29, Bogotá, DC 0571, Colombia. Tel.: +57 3406593.
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Tel.: +57 3406593." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome posparo cardiaco" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1972 the Russian pathophysiologist Vladimir Negovsky described the syndrome as “a post-resuscitation disease”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, since it involves a series of uncontrolled events, the International Liaison Committee on Resuscitation (ILCOR) adopted the term post cardiac arrest syndrome.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence rate due to all cardiac causes is 460,000 deaths/year.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Prospective trials refer to 350,000 coronary disease-related deaths/year; this is 1–2/1000 people for the American population.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There are survival reports of patients with extra-hospital cardiac arrest of 23.8% at the time of admission and of 7.6% at the time of discharge.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Biological death depends on the cardiac arrest mechanism, on the underlying disease and on the delay in starting the resuscitation maneuvers (CPR). A poor neurological prognosis after 4–6<span class="elsevierStyleHsp" style=""></span>min of an unattended arrest is irreversible,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and hence resuscitation must be a constant mission.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When the arrest mechanism is an asystole or a pulseless electrical activity (PEA), the progression to neurological injury is faster and leads to a worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Mild therapeutic hypothermia (32–34<span class="elsevierStyleHsp" style=""></span>°C) is the gold standard in post-arrest care.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A narrative review of the literature using Medline via PubMed and Clinical Trials using the terms MeSH cardiac arrest – Cardiopulmonary Resuscitation and no term MeSH Post cardiac arrest syndrome was carried out.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical evolution</span><p id="par0035" class="elsevierStylePara elsevierViewall">Once the patient recovers spontaneous cardiac circulation, a cascade of events develops, mainly characterized by anoxic brain injury, post cardiac arrest myocardial dysfunction, “ischemic/reperfusion” systemic response, and the typical pathology of the triggering cause of the cardiac arrest. The clinical evolution shall be dependent on clinical conditions such as the patient's co-morbidities, the duration of the ischemic lesion and the cause that triggered the cardiac arrest.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Pathophysiology</span><p id="par0040" class="elsevierStylePara elsevierViewall">Oxygen deficiency and generalized acidosis develop during cardiac arrest. If the victim is resuscitated using CPR/defibrillation maneuvers, with resumption of spontaneous circulation, PCSS develops, which is characterized by a systemic inflammatory response of the immune system and of coagulation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Cell damage seems to affect the enzyme calpain and peroxidation caused by oxygen free radicals that begin to develop during the phase of global ischemia and perpetuates during reperfusion.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main cause of extra-hospital cardiac arrest in the adult is acute myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> There are many other pathologies leading to multisystem failure and subsequent cardiac arrest in the hospitalized patient.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">According to the ILCOR<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,10</span></a> document, the PCAS classification follows physiological criteria in five phases:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Immediate care: the initial 20<span class="elsevierStyleHsp" style=""></span>min following the patient's spontaneous recovery of circulation.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Early phase: from 20<span class="elsevierStyleHsp" style=""></span>min to 6–12<span class="elsevierStyleHsp" style=""></span>h, when critical protective and therapeutic measures are required for a successful outcome.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Intermediate phase: from 6–12<span class="elsevierStyleHsp" style=""></span>h to 72<span class="elsevierStyleHsp" style=""></span>h a close surveillance and ICU treatment are required consistent with the therapeutic objectives.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Recovery phase: comprises the patient's condition after the initial 72<span class="elsevierStyleHsp" style=""></span>h when there is a clearer diagnosis and a more predictable result.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Rehabilitation phase: focuses on the patient's complete recovery. Any electrolytic abnormalities shall be corrected during phases 1 and 2, in addition to providing inotropic support and optimized oxygenation.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></li></ul></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Goal-targeted therapy</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ventilation support</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1.</span><p id="par0085" class="elsevierStylePara elsevierViewall">Normocapnia (PaCO<span class="elsevierStyleInf">2</span> between 40 and 45<span class="elsevierStyleHsp" style=""></span>mmHg). However, arterial gasometry should be properly interpreted in patients undergoing therapeutic hypothermia. When a patient reaches a central body temperature of close to 33<span class="elsevierStyleHsp" style=""></span>°C, the actual PaCO<span class="elsevierStyleInf">2</span> may be up to 7<span class="elsevierStyleHsp" style=""></span>mmHg below the value in the arterial gases machine.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Hyperventilation has been associated with a drop in coronary perfusion and venous return, in addition to cerebral vasoconstriction.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Normoxia. Both, hypoxia and hyperoxia (PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>mmHg) may result in secondary neurological injury. Using an inspired oxygen fraction to maintain the arterial saturation between 95% and 99% or a PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg is considered very reasonable.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, other authors have not achieved similar results.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Hemodynamic support</span><p id="par0095" class="elsevierStylePara elsevierViewall">Systemic perfusion and in particular cerebral perfusion have prognostic implications. Cardiac arrest patients experience a loss of cerebral self-regulation. Based on positron emission tomography studies, the suggestion is to maintain a mean pressure between 80 and 100<span class="elsevierStyleHsp" style=""></span>mmHg because this is the range in which perfusion matches the cerebral metabolic activity.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> During the first 48–72<span class="elsevierStyleHsp" style=""></span>h following the cardiac arrest, vasopressors and inotropic agents are usually needed. Transthoracic echocardiography may assist in accomplishing this goal. Apparently there is no difference in terms of the clinical prognosis regardless of the vasopressor (norepinephrine versus dopamine). Monitoring the mixed venous saturation may help in the interpretation of pharmacological interventions such as the introduction of inotropic agents.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Hypothermia has shown huge benefits since 2002;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> however, the procedure is not standardized in every country. There is an Italian study in ICUs indicating that only 16% used the therapeutic hypothermia protocol.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hypothermia Management Scheme<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></span><p id="par0105" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1.</span><p id="par0110" class="elsevierStylePara elsevierViewall">The induction phase (body temperature between 32<span class="elsevierStyleHsp" style=""></span>°C and 34<span class="elsevierStyleHsp" style=""></span>°C). It should be started early to prevent neuro-excitotoxicity.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> It has been shown that the benefit of hypothermia will not be achieved if it is introduced after 6<span class="elsevierStyleHsp" style=""></span>h of the spontaneous return of circulation.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Both PRINCE (Pre-ROSC Intranasal Cooling Effectiveness)<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and Nagao<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> trials showed that initiating hypothermia before the patient recovers spontaneous cardiac circulation during CPR improves the neurological results and protects the myocardium from reperfusion injuries. Therapeutic hypothermia may not last less than 6<span class="elsevierStyleHsp" style=""></span>h and it should be continued for 12–24<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Some recommend starting a rapid saline solution infusion at 4<span class="elsevierStyleHsp" style=""></span>°C to accomplish these goals.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The rate at which the body temperature drops is close to 1<span class="elsevierStyleHsp" style=""></span>°C in 15<span class="elsevierStyleHsp" style=""></span>min, when administering 1 liter of cold saline solution. This method is thought to be comparable to or even better than the use of intravascular catheters.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> The infusion of 30<span class="elsevierStyleHsp" style=""></span>ml/kg of saline solution at 4<span class="elsevierStyleHsp" style=""></span>°C lowers the body temperature at a rate of over 2<span class="elsevierStyleHsp" style=""></span>°C/h.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,32</span></a> Chills are one of the side effects of cooling down because of the rise in metabolic oxygen consumption; the recommendation to prevent chills includes administering magnesium sulfate (5<span class="elsevierStyleHsp" style=""></span>g/5<span class="elsevierStyleHsp" style=""></span>h), sedation and proper analgesia, in addition to the occasional administration of muscle relaxants.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,24</span></a> A very common intravenous sedation regime is titrating with a continuous infusion of Propofol (up to 50<span class="elsevierStyleHsp" style=""></span>μg/kg/min) and Fentanyl. Hypothermia between 32<span class="elsevierStyleHsp" style=""></span>°C and 34<span class="elsevierStyleHsp" style=""></span>°C results in a drop in cardiac output (between 25% and 40%) at the expense of a heart rate decrease. Arrhythmias occur at much lower temperatures than these ranges or as a result of electrolyte imbalances.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The most destabilizing factors during this phase are hypovolemia and electrolyte imbalances (hypokalemia and hypomagnesemia). Increased diuresis results in a hydro-electrolytic imbalance, hemoconcentration and a rise in blood viscosity.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2.</span><p id="par0120" class="elsevierStylePara elsevierViewall">The maintenance phase should be free of any temperature variations beyond 0.2–0.5 degrees centigrade of the temperature achieved. Be very careful with the metabolic requirements of the patient since these are reduced in up to 50% and monitor coagulation, although different trials do not show a significant risk of bleeding.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,34</span></a> Hypothermia extends the half-life of all drugs. The administration of muscle relaxants may suppress chills and hence prevent rises in body temperature. However, muscle relaxants may mask seizures (that are present in up to 44% of the cases).<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The therapeutic approach includes the use of multiple anti-convulsive agents as is the case in status epilepticus (valproic acid, phenytoin, midazolam, phenobarbital and propofol) because seizures tend to be refractory.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3.</span><p id="par0125" class="elsevierStylePara elsevierViewall">The premise during the warm-up phase is to slowly recover the temperature at a rate of 0.2–0.3 degrees centigrade. It is recommended to start warming-up after 12–24<span class="elsevierStyleHsp" style=""></span>h of introducing the hypothermia until the temperature is normalized.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,24</span></a> It is usual to experience hyperkalemia, cerebral edema, and seizures during this phase; likewise, ruling out any risk of infection is a priority since one of the effects of hypothermia is the inhibition of the immune response. The use of antibiotic prophylaxis is only indicated for high-risk patients or in prolonged hypothermia (over 48<span class="elsevierStyleHsp" style=""></span>h).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The level of coagulopathy is considered to be mild when compared against that of cardiac arrest victims who are maintained at a normal temperature.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Increased infection rates have been described associated with therapeutic hypothermia for 24<span class="elsevierStyleHsp" style=""></span>h; however, it has not been associated with higher mortality.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,39</span></a> There can also be bradycardia, prolongation of the QTc segment, hyperglycemia, diuresis with subsequent hypokalemia, hypomagnesemia and hypofosfatemia.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Hypothermia protection</span><p id="par0130" class="elsevierStylePara elsevierViewall">During the first phase, when the patient recovers spontaneous circulation, hypothermia reduces the metabolic consumption of oxygen and glucose.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">During the second phase, hypothermia reduces the occurrence of excitatory amino acids, particularly glutamate; these amino acids are responsible for the activation of the cytotoxic cascade, the formation of reactive oxygen species (ROS) and nitric oxide.</p><p id="par0140" class="elsevierStylePara elsevierViewall">During the third phase, hypothermia preserves the integrity of cell membranes interfering with the action of calpain and thus preventing the occurrence of cerebral edema, neuronal death and blood brain barrier injury.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41–43</span></a><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><p id="par0145" class="elsevierStylePara elsevierViewall">The benefits of therapeutic hypothermia have been very well explained in a recent meta-analysis. Patients treated with therapeutic hypothermia exhibited improved neurological function (RR 1.55; 95 CI 1.22–1.96) and had a higher probability of survival at discharge (RR 1.35; 95 CI 1.10–1.65) compared to patients not treated with hypothermia.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><p id="par0150" class="elsevierStylePara elsevierViewall">The international agencies (AHA – ERC) have accepted and promoted the indication of hypothermia for managing the post cardiac arrest syndrome, not only in defibrillator-amenable patients, but also in cases of worse AESP prognosis and asystole in which the most important prognostic factor is the <span class="elsevierStyleItalic">initiation of therapy</span>.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,29</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Indications for therapeutic hypothermia</span><a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,45</span></a><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0070"><p id="par0160" class="elsevierStylePara elsevierViewall">Return to spontaneous cardiac circulation following cardiac arrest (any type of rhythm)</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0165" class="elsevierStylePara elsevierViewall">Coma</p></li><li class="elsevierStyleListItem" id="lsti0080"><p id="par0170" class="elsevierStylePara elsevierViewall">Over 18 years old</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0085"><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Absolute contraindications</span><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0090"><p id="par0180" class="elsevierStylePara elsevierViewall">Non-compressible active bleeding</p></li><li class="elsevierStyleListItem" id="lsti0095"><p id="par0185" class="elsevierStylePara elsevierViewall">Do not resuscitate medical order (DNR)</p></li></ul></p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">The hypothermia protocol must be interrupted in the presence of sepsis or pneumonia, refractory hemodynamic instability and severe refractory arrhythmia.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Hypothermia in patients with a FV cardiac arrest has an NNT of 6 (confidence interval of 4–13). Despite the consistency of the trials in terms of the rhythm of presentation of the arrest, cooling method used, time to reach therapeutic hypothermia and duration thereof, no follow-up studies have been made beyond one year to establish the final neurological involvement.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Hypothermia should not be delayed, even when the patient requires transluminal percutaneous coronary angioplasty.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The best site to monitor the central temperature is through the pulmonary artery catheter or the central venous line; however, other sites are recommended such as the esophagus and the bladder, because they are easy to place and have minimal effects.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,48</span></a> The bladder temperature may be misinterpreted in the presence of oliguria.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">When should you do percutaneous coronary intervention (PCI) and thrombolysis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Ask about any history of coronary heart disease, prior chest pain symptoms and initial arrest rhythm (if the QRS tracing in the ECG is widened, it is most likely of coronary etiology); however, the literature has not found a positive predictive value for coronary obstruction of these two parameters.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Thrombolysis is only recommended in isolated cases of pulmonary embolism and acute myocardial infarction with ST elevation (IAMST) and a 3-h therapeutic window or in the case of IAMST, with no other option for invasive coronary intervention.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In cardiac arrest patients with no evident extra cardiac cause or who present ST elevation in the ECG or sudden left branch blockade, an early angiographic exploration is recommended, followed by percutaneous coronary intervention.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> In a report written by Spaulding et al.,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> 49% of all cardiac arrest survivors who underwent routine coronary angiography showed a severe coronary obstruction.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Further randomized clinical trials are needed showing the positive impact of emergency percutaneous coronary intervention in this syndrome. As of now, the studies reporting benefits with the use of PCI-associated therapeutic hypothermia exhibit various biases and undetermined confounding factors.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The similarity of the cardiohemic involvement of PCAS<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> to septic shock has led to the search of alternative aggressive management options with quite successful results such as circulatory support with extracorporeal oxygenation<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> and renal replacement therapy with high volume hemofiltration.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">In refractory cardiac arrest patients, the alternative to use venous-arterial extracorporeal membrane oxygenation and PCI has been suggested.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Recommendation for neurological follow-up of the patient</span><p id="par0240" class="elsevierStylePara elsevierViewall">The brain is the key organ in resuscitation, hence the high importance given to therapeutic hypothermia.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> There is an interesting article on the “self-fulfilling prophecy”<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> that states that no negative prior judgments should be made in a patient who has overcome the arrest, regardless of the cause because by not doing what should be done, the patient will not survive, giving the false impression that what is appropriate is not to start any medical intervention under these circumstances. However, there is always room for uncertainty in every prognosis.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">The prognosis after the clinical and paraclinical exams at different points in the evolution must have a 72-h (3 days) period of observation before any decision is made.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> The American Academy of Neurology suggests that in the absence of brain death, findings of the clinical examination such as absence of corneal or pupillary reflexes, of motor response or extended absence of motor response, lead to a high rate or poor prognosis and consequently low false positives.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Efforts have been made to identify serum markers for predicting the development of multiple organ failure in PCAS patients. Soluble Ang1 factor stabilizes the endothelium Ang2 levels, and a higher proportion of Ang2/Ang1 is predictive of multiple organ failure and poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">High procalcitonin levels are shown to be associated with PCAS and adverse neurological prognosis rather than to early infection in patients with anoxic encephalopathy.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a> Among the clinical factors themselves, a research comparing two hospitals in distant geographical regions showed that the pre- and intra-cardiac arrest conditions determine the severity of the PCAS.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Prognostic factors<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></span><p id="par0315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0265" class="elsevierStylePara elsevierViewall">Patient history: old age – diabetes – sepsis – CVA</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Cardiac arrest and resuscitation conditions: time elapsed since the cardiac arrest and the start of CPR – CPR quality – asystole as arrest rhythm – implementation of a protocol for managing the PCAS.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Later evolution in accordance with the neurological examination, neurophysiological exams, neuroimaging, biochemical markers and intracranial Doppler.</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">The two scales used to establish the degree of disability and the quality of life are the Glasgow prognostic scale<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and the Glasgow-Pittsburgh<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> scale for categorizing brain performance.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">What is currently being done?</span><p id="par0285" class="elsevierStylePara elsevierViewall">A large international prospective trial was completed coordinated from Sweden<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> – the TTM trial (Target Temperature Management, identified as <a id="intr0005" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01020916">NCT01020916</a>), whose results were published late in 2013. The purpose of the trial was to establish the level of evidence of hypothermia for the management of PCAS with optimal control to avoid hyperthermia in both groups; <span class="elsevierStyleItalic">n</span>: 939 adult patients. Comparison: controlled hypothermia (33<span class="elsevierStyleHsp" style=""></span>°C) versus patients maintained with a temperature of 36<span class="elsevierStyleHsp" style=""></span>°C. Period of time during which the patients were evaluated: up to 180 days. The results obtained are controversial with regard to the optimal threshold of hypothermia. The conclusion of the trial was based on a strict temperature control (below 36<span class="elsevierStyleHsp" style=""></span>°C) to prevent hyperthermia, which is considered a determining factor for poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a> Emphasis was also placed on the establishment of standardized protocols, even for each subgroup of patients who may benefit from individualized treatment.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">The recommendation is to optimize the perfusion of vital organs in addition to the brain, since the prevalence of multiple extra-cerebral organ failure impacts mortality, particularly the involvement of the cardiovascular (depends on the fine vasopressor support) and respiratory system (by providing improved oxygenation). An independent association has been identified between these two organs and their involvement has been linked to a higher hospital mortality in PCAS.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusion</span><p id="par0295" class="elsevierStylePara elsevierViewall">PCAS is an entity that has been recognized for the last 40 years; however, the treatment for PCAS has only been established in an organized manner in the last decade.</p><p id="par0300" class="elsevierStylePara elsevierViewall">The pathophysiology includes a serious involvement of the brain and leads to myocardial dysfunction and systemic inflammation. Failure to intervene early on results in irreversible brain injury, vegetative state and death.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0305" class="elsevierStylePara elsevierViewall">Authors.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "xres329752" "titulo" => array:6 [ 0 => "Abstract" 1 => "Background" 2 => "Objective" 3 => "Methodology" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec311632" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres329753" "titulo" => array:6 [ 0 => "Resumen" 1 => "Antecedentes" 2 => "Objetivo" 3 => "Metodología" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec311631" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical evolution" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Pathophysiology" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Treatment" "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Goal-targeted therapy" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Ventilation support" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Hemodynamic support" ] ] ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Hypothermia Management Scheme" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Hypothermia protection" ] ] ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "When should you do percutaneous coronary intervention (PCI) and thrombolysis" ] 9 => array:3 [ "identificador" => "sec0055" "titulo" => "Recommendation for neurological follow-up of the patient" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Prognostic factors" ] ] ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "What is currently being done?" ] 11 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusion" ] 12 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 13 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-29" "fechaAceptado" => "2014-01-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec311632" "palabras" => array:5 [ 0 => "Heart arrest" 1 => "Cardiopulmonary resuscitation" 2 => "Percutaneous coronary intervention" 3 => "Hypothermia induced" 4 => "Blood Circulation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec311631" "palabras" => array:5 [ 0 => "Paro cardiaco" 1 => "Resucitación cardiopulmonar" 2 => "Intervención coronaria percutánea" 3 => "Hipotermia inducida" 4 => "Circulación sanguínea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Resuscitation from cardiac arrest with global ischemia restores spontaneous circulation in some patients; however, survival depends on many factors associated with post cardiac arrest syndrome. During the last ten years, the understanding and control of these factors have improved the prognosis in a subgroup of patients.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the pathophysiology and current management of the post cardiac arrest syndrome (PCAS).</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methodology</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Narrative review of the literature using Medline via PubMed and Clinical Trials, using the terms MeSH cardiac arrest – Cardiopulmonary Resuscitation and (no term MeSH) Post cardiac arrest syndrome.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical trials have established a set of management protocols and guidelines based on therapeutic objectives with survival rates exceeding 50% of the cardiac arrest victims.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The management of this syndrome has actually strengthened the last link in the survival chain by standardizing the evaluation and selection of cardiac arrest victims via a therapeutic hypothermia protocol and early percutaneous coronary intervention.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La reanimación en el paro cardiaco con isquemia global logra restablecer la circulación espontánea en algunos pacientes; sin embargo, la sobrevida depende de muchos factores que explican el síndrome posparo cardiaco. El entendimiento y el control de estos factores durante la última década han logrado mejorar el pronóstico en un subgrupo de pacientes.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la fisiopatología y el manejo actual del síndrome posparo cardiaco.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Metodología</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Revisión narrativa de la literatura a través de las bases electrónicas de Medline vía PubMed y Ensayos Clínicos usando los términos MeSH <span class="elsevierStyleItalic">Cardiac arrest – Cardiopulmonary Resuscitation</span> y (el término no MeSH) <span class="elsevierStyleItalic">Post cardiac arrest syndrome.</span></p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los estudios clínicos han establecido una serie de protocolos y guías de manejo basadas en objetivos terapéuticos con tasas de sobrevida que superan el 50% de las víctimas de paro cardiaco.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Actualmente el manejo de este síndrome ha fortalecido el último eslabón dela cadena de supervivencia al estandarizar la evaluación y la selección de víctimas de paro cardiaco con un protocolo de hipotermia terapéutica e intervención coronaria percutánea precoz.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Navarro-Vargas JR, Díaz JL. Síndrome posparo cardiaco. Rev Colomb Anestesiol. 2014;42:107–113.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:66 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The second step in resuscitation: the treatment of the “post-resuscitation disease”" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "V.A. 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Year/Month | Html | Total | |
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2024 November | 3 | 0 | 3 |
2024 October | 22 | 5 | 27 |
2024 September | 42 | 4 | 46 |
2024 August | 36 | 7 | 43 |
2024 July | 34 | 12 | 46 |
2024 June | 31 | 6 | 37 |
2024 May | 26 | 6 | 32 |
2024 April | 50 | 16 | 66 |
2024 March | 83 | 21 | 104 |
2024 February | 240 | 15 | 255 |
2024 January | 44 | 19 | 63 |
2023 December | 62 | 10 | 72 |
2023 November | 64 | 21 | 85 |
2023 October | 34 | 22 | 56 |
2023 September | 46 | 13 | 59 |
2023 August | 33 | 11 | 44 |
2023 July | 33 | 15 | 48 |
2023 June | 39 | 5 | 44 |
2023 May | 92 | 15 | 107 |
2023 April | 73 | 13 | 86 |
2023 March | 69 | 16 | 85 |
2023 February | 37 | 10 | 47 |
2023 January | 23 | 16 | 39 |
2022 December | 43 | 3 | 46 |
2022 November | 33 | 7 | 40 |
2022 October | 26 | 18 | 44 |
2022 September | 21 | 10 | 31 |
2022 August | 28 | 17 | 45 |
2022 July | 21 | 10 | 31 |
2022 June | 28 | 9 | 37 |
2022 May | 17 | 27 | 44 |
2022 April | 42 | 34 | 76 |
2022 March | 84 | 26 | 110 |
2022 February | 50 | 33 | 83 |
2022 January | 42 | 22 | 64 |
2021 December | 32 | 31 | 63 |
2021 November | 52 | 22 | 74 |
2021 October | 47 | 22 | 69 |
2021 September | 37 | 16 | 53 |
2021 August | 39 | 20 | 59 |
2021 July | 33 | 28 | 61 |
2021 June | 28 | 12 | 40 |
2021 May | 53 | 16 | 69 |
2021 April | 190 | 84 | 274 |
2021 March | 206 | 83 | 289 |
2021 February | 58 | 18 | 76 |
2021 January | 55 | 16 | 71 |
2020 December | 58 | 14 | 72 |
2020 November | 66 | 10 | 76 |
2020 October | 28 | 6 | 34 |
2020 September | 40 | 21 | 61 |
2020 August | 36 | 21 | 57 |
2020 July | 16 | 5 | 21 |
2020 June | 14 | 7 | 21 |
2020 May | 14 | 7 | 21 |
2020 April | 15 | 10 | 25 |
2020 March | 23 | 21 | 44 |
2020 February | 12 | 7 | 19 |
2020 January | 22 | 4 | 26 |
2019 December | 13 | 10 | 23 |
2019 November | 5 | 6 | 11 |
2019 October | 4 | 5 | 9 |
2019 September | 5 | 0 | 5 |
2019 August | 2 | 0 | 2 |
2019 July | 6 | 12 | 18 |
2019 June | 2 | 0 | 2 |
2019 May | 1 | 10 | 11 |
2018 September | 1 | 0 | 1 |
2018 August | 0 | 1 | 1 |
2018 June | 5 | 2 | 7 |
2018 May | 31 | 12 | 43 |
2018 April | 45 | 7 | 52 |
2018 March | 24 | 7 | 31 |
2018 February | 24 | 6 | 30 |
2018 January | 49 | 6 | 55 |
2017 December | 35 | 6 | 41 |
2017 November | 41 | 8 | 49 |
2017 October | 36 | 9 | 45 |
2017 September | 54 | 9 | 63 |
2017 August | 59 | 7 | 66 |
2017 July | 55 | 5 | 60 |
2017 June | 79 | 7 | 86 |
2017 May | 94 | 8 | 102 |
2017 April | 81 | 19 | 100 |
2017 March | 80 | 11 | 91 |
2017 February | 55 | 10 | 65 |
2017 January | 47 | 10 | 57 |
2016 December | 55 | 12 | 67 |
2016 November | 52 | 12 | 64 |
2016 October | 62 | 10 | 72 |
2016 September | 81 | 18 | 99 |
2016 August | 67 | 21 | 88 |
2016 July | 42 | 19 | 61 |
2016 June | 0 | 18 | 18 |
2016 May | 2 | 20 | 22 |
2016 April | 1 | 33 | 34 |
2016 March | 2 | 37 | 39 |
2016 February | 1 | 0 | 1 |
2016 January | 1 | 21 | 22 |
2015 December | 14 | 15 | 29 |
2015 November | 74 | 18 | 92 |
2015 October | 81 | 16 | 97 |
2015 September | 58 | 13 | 71 |
2015 August | 57 | 12 | 69 |
2015 July | 59 | 15 | 74 |
2015 June | 46 | 8 | 54 |
2015 May | 57 | 9 | 66 |
2015 April | 46 | 12 | 58 |
2015 March | 48 | 11 | 59 |
2015 February | 49 | 9 | 58 |
2015 January | 43 | 8 | 51 |
2014 December | 62 | 15 | 77 |
2014 November | 42 | 11 | 53 |
2014 October | 50 | 12 | 62 |
2014 September | 54 | 20 | 74 |
2014 August | 53 | 20 | 73 |
2014 July | 66 | 24 | 90 |
2014 June | 87 | 18 | 105 |
2014 May | 105 | 16 | 121 |
2014 April | 171 | 20 | 191 |